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HEALTH SYSTEM TRANSFORMATION IN MYANMAR:ARE THE CURRENT CHANGES PROMISING? 5/26/2015 Phyu Phyu Thin Zaw, MBBS, PhD VisiHng Scholar/WHOHRP Career Development Fellow Asia Health Policy Program ShorensteinAPARC 1

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Page 1: HEALTHSYSTEMTRANSFORMATION INMYANMAR RE THE … · 2016" !Expansion of payroll tax financed social health insurance for formal sector (private and civil servant)!" !Development of

HEALTH  SYSTEM  TRANSFORMATION  IN  MYANMAR:  ARE  THE  CURRENT  CHANGES  PROMISING?  

5/26/2015  

Phyu  Phyu  Thin  Zaw,  MBBS,  PhD  VisiHng  Scholar/WHO-­‐HRP  Career  Development  Fellow  

Asia  Health  Policy  Program  Shorenstein-­‐APARC  

1  

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●  Myanmar  profile  ●  Myanmar’s  current  health  status  ●  Myanmar  Health  System      

●  Overview  ●  Comparison  with  South  East  Asian  countries  

●  Equity  of  access  to  ReproducBve  Health  services  ●  Current  Changes  in  Myanmar  Health  System  ●  Conclusions  and  RecommendaBons  

2  

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PoliHcs  ❖   Was  the  second  most  isolated  country  next  to  North  Korea  from  1962  to  2012  ❖ In  a  transiBonal  period  aMer  63  years  of  military  regime    ❖ Increased  transparency  ❖   More  freedom  of  speech,  moderate  media  freedom  ❖ Some  posiBve  approaches    

AdministraHve  Division  • 7  Regions  • 7  States  Area  :Slightly  smaller  than  the  U.S.  state  of  Texas.    Neighbors  :  China,  India,  Thailand,  Bangladesh  and  Laos  

❖ Once  South  East  Asia’s  wealthiest  naBon    

(Ref:  2014  census,  WHO  2011)  

3  

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Ethnicity  • Over  130  ethnic  groups  with  8  major  groups  • Internal  Conflicts:  One  of  the  longest  civil  wars  • Abundant  natural  resources:  2nd  lowest  Human  Development  Index    in  Asia  Pacific  Region  

Beautiful Myanmar"

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http://www.placestoseeinyourlifetime.com/bagan-a-strikingly-beautiful-ancient-city-in-myanmar-8843/ PHOTO CREDIT

Beautiful Myanmar!

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World  Bank,  2013  Wikipedia  contributor  2013  

Page 7: HEALTHSYSTEMTRANSFORMATION INMYANMAR RE THE … · 2016" !Expansion of payroll tax financed social health insurance for formal sector (private and civil servant)!" !Development of

1.  Life  Expectancy  2.  Maternal  Mortality  3.  Infant  Mortality  4.  Prevalence  of  Communicable  Diseases  (HIV/

TB/Malaria)  5.  Prevalence  of  Non-­‐communicable  diseases  

7  

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Life  expectancy  in  Myanmar  Male:  63.4  Female:  67.1  Total:  65.2  

8  

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Maternal  Mortality  RaHos  and  Percentage  of  Skilled  Birth  AZendant  in  SEAR  

9  

"   200  per  100,000  live  births  "   Three  quarters  of  all  maternal  

deaths  occur:    "   Delivery    "   Immediate  post-­‐partum  period  

"   Low  access  to  essenBal  maternal  health  services    

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"   IMR:  48  naBonally;    94.2  in  the  east  "    Under  Five  Mortality  Rate:    

"   62  naBonally  "   141.9  in  the  east  

"    Highest  in  Southeast  Asia  UNICEF  report  2013  

10  

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11  

Source:  Ministry  of  Health,  Myanmar  

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Global  Tuberculosis  report  WHO-­‐2013;  Beyrer  2006  

•  High  burden  of  CD:  tuberculosis  (TB),  malaria  and  HIV/AIDS  •  Top  three  naBonal  priority  diseases  of  Myanmar  (MOH,  2013)  

12  

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13   Num

ber  o

f  you

ths  living  with

 HIV  

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14  

Source:    World  Health  OrganizaHon  -­‐  Noncommunicable  Diseases  (NCD)  Country  Profiles,  2014.    

Five  Risk  Factors    1.  Dietary  risks  2.  Tobacco  smoking  3.  Household  air  polluBon  from  

solid  fuels  4.  High  blood  pressure    5.  High  fasBng  plasma  blood  sugar    (IHME,  2010)  

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15  

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Colonial Period: British Health

System"

After independence: Health System was

temporarily interrupted"

Democratization Period"

Military Regime"The first major reform to achieve UHC (Health for

All)"

"   Lack  of  government  investment  in  healthcare  

"   RestricBon  of  NGO  provision  of  health  services  

✓ EradicaBon  of  smallpox  1977      

✓ EliminaBon  of  leprosy,  trachoma,  poliomyeliBs,  and  iodine-­‐deficiency  

disorders  

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❖   A  pluralisBc  mix  of  public  and  private  systems  both  in  financing  and  provision    

17  

The  WHO  Health  Systems  Framework  

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Union  Minister  for  Health  

Deputy  Minister    

❖   NaHonal  Health  Policy  ❖ NaHonal  Health  Plan  ❖   Myanmar  Health  Vision  2030  ❖     Rural  Health  Development  Plan  

 Deputy  Minister    

   UN  Agencies,  Bilateral,  INGOs,  …  

Other  Ministries  NaHonal  NGOs,  Private  Sector  

Permanent  Secretary  Office  

18  

Department  of  TradiBonal    Medicine  

Department  of  Medical  Research   Department  of  FDA  

Department  of  Medical  Care  

Department  of    Public  Health  

Department  of  health  professional  Resource  development  and  management  

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●  The  government  used  to  be  the  main  source  of  financing  ●  Private  out-­‐of-­‐pocket  (OOP)  payment  became  the  main  source  of  finance:  cost  

sharing  in  1993    ●  Total  health  expenditure  in  Myanmar:  2.0–2.4%  of  its  GDP  between  2001  -­‐2011  ●  The  lowest  among  countries  in  the  World  Health  OrganizaBon  ●  Donor  contribuHons  remain  substanBal,  at  7%  of  total  health  expenditure  in  

2011  (half  what  the  government  spends  on  health).  

19  

Source:  Asia  Pacific  Observatory  on  Health  Systems  and  Policies  

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Source:  Department  of  Health  Planning,  Ministry  of  Health,  Myanmar  

0.0%  

25.0%  

50.0%  

75.0%  

100.0%  

1998   1999   2000   2001   2002   2003   2004   2005   2006   2007   2008   2009   2010   2011  

GGHE  as  %  of  THE  PrivHE  as  %  of  THE  

20  

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%  of  total  health

 expen

diture  

21  

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%  of  G

DP  

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Page 24: HEALTHSYSTEMTRANSFORMATION INMYANMAR RE THE … · 2016" !Expansion of payroll tax financed social health insurance for formal sector (private and civil servant)!" !Development of

●  Nearly  100%  of  private  health  expenditure  (2001  -­‐2011)  ●  Over  30%  of  households  encountered  catastrophic  health  expenditure  

(MOH  &  UNICEF  unpublished  informaBon,  2012)    

24   Out-­‐of-­‐pocket  Health  Expenditure  in  SEAR  (1995-­‐2011)  

%  of  total  health

 expen

diture  

Page 25: HEALTHSYSTEMTRANSFORMATION INMYANMAR RE THE … · 2016" !Expansion of payroll tax financed social health insurance for formal sector (private and civil servant)!" !Development of

●  No  health  insurance  system  at  all  in  Myanmar  ●  Social  security  system  :  established  in  1956  ◦  For  insured  workers  who  are  employed  in  the  private  sector    ◦  For  enterprises  having  more  than  five  employees    ◦  Benefits  :  free  medical  care  during  illness,  payment  of  75%  of  basic  salary  

during  maternity  leave,  full  salary  for  one  year  for  severe  injuries,  cash  payments  for  death  and  injury,  and  survivors’  pension  

●  The  scheme  covers  less  than  1%  of  the  populaHon    

25  

Source:  Asia  Pacific  Observatory  on  Health  Systems  and  Policies  

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●  The  Department  of  Medical  Science  :  doctors,  nurses  and  health  care  workers  ●  Density  of  physicians:  0.501    per  1000  populaBon  ●  It  was  sBll  far  below  the  global  standard  of  2.28  health  workers  per  1000  populaBon  ●  UnderproducHon  of  dental  surgeons,  pharmacists  and  technicians  as  compared  to  doctors  

and  nurses.  ●  Limited  registraHon  for  foreign  doctors  to  work  in  Myanmar  

26  

Source:  Ministry  of  Health,  Myanmar,  unpublished  data  

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27  

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28  

Source:  Asia  Pacific  Observatory  on  Health  Systems  and  Policies  

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Page 30: HEALTHSYSTEMTRANSFORMATION INMYANMAR RE THE … · 2016" !Expansion of payroll tax financed social health insurance for formal sector (private and civil servant)!" !Development of

ScaZer  plot  showing  discrepancy  index  of  hospital  beds  and  hospital  uHlizaHon  

●  Looking  at  the  distribuBon  of  health  care  faciliBes  and  beds  across  the  country,  inequiBes  are  evident.    

●  A  discrepancy  index  lower  than  1.0  means  that  a  region  or  state  has  fewer  beds  per  1000  populaBon  than  the  naBonal  average  (1.0).  

30  

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EssenHal  Medicine  List  ●  The  Myanmar  EssenBal  Drugs  Programme  has  revised  the  NaBonal  List  of  

EssenBal  Medicines  ●  The  Central  Medical  Store  Depot  (CMSD)  procured  a  subset  of  92  medicines  from  

the  essenBal  medicine  list  in  2010  ●  The  Ministry  of  Finance  did  not  provide  enough  funds  to  procure  all  the  needed  

essenBal  medicine  (Holloway,  2011)  Ministry  of  Health,  Myanmar,  unpublished  data  

31  

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●  General  radiography  (e.g.  X-­‐ray  machines)  represents  as  most  basic  equipment  available  at  township  and  staBon  hospitals  across  the  country.    

●  Computed  tomography  (CT)  was  only  available  in  Yangon  and  Mandalay  General  Hospitals  unBl  2012.    

●  Five  magneBc  resonance  imaging  (MRI)  scanners  are  operated  in  big  ciBes.  ●  There  is  a  need  to  strengthen  regular  maintenance  mechanism  of  medical  

devices.  

32  Source:  Asia  Pacific  Observatory  on  Health  Systems  and  Policies  

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Source:  Asia  Pacific  Observatory  on  Health  Systems  and  Policies  

●  Comprises  hospital  informaBon,  public-­‐health  informaBon,  human-­‐resources  informaBon  and  logisBcal  informaBon  

●  Data  are  collected  manually  by  individual  using  standardized  forms  ●  DisseminaBon  of  staBsBcs  :  an  annual  public  health  staHsHcs  report  ●  Due  to  lack  of  adequate  resources  and  capacity,  populaBon-­‐based  surveys  could  

not  be  carried  out  as  frequently  as  needed  

33  

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Information Technology

Trends  in  Internet  Users  in  Government  Sector  and  General  Public  

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35  

Patient"

Rural Health Center"

Urban Health Center"

Small clinics run by GPs"

Traditional Medicine"

Station Hospital"

Village Volunteers or Midwifes"

Township Hospital"

District Hospital"

Public Tertiary Hospital"

Private Tertiary Hospital"

Private Hospital"

Rural  A

rea  

Urban

 Area  

Traditional Medicine Clinics"

SECONDARY CARE TERTIARY CARE PRIMARY  CARE  

Page 36: HEALTHSYSTEMTRANSFORMATION INMYANMAR RE THE … · 2016" !Expansion of payroll tax financed social health insurance for formal sector (private and civil servant)!" !Development of

●  Second  worst  in  terms  of  ‘overall  health  system  performance’  by  the  WHO  in  2000    

●  OOP  payment  is  the  highest  in  the  world,  at  81%  of  total  health  expenditures  

●  EsBmated  three-­‐quarters  of  Myanmar’s  ciBzens  find  themselves  with  very  limited  access  to  essenBal  health  services  

World  Bank  (2012)  

36  

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Equity  of  Access  to  ReproducHve  Health  Services    Among  Youths  in  Poor  CommuniHes  of  Mandalay  City  

Phyu  Phyu  Thin  Zaw,  Tippawan  Liabsueltrakul,  Edward  McNeil,  Thein  Thein  Htay  BMC  Health  Serv  Res.  2012  Dec  15;12:458.  doi:  10.1186/1472-­‐6963-­‐12-­‐458.  

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Map  of  Myanmar  

Thailand  

India  

China  Mandalay  city  "   PopulaBon:    

nearly  1  million  "   EsBmated  10  ‘resource-­‐

limited’  suburban  communiBes    

"   50,000  living  in  ‘resource-­‐limited’  suburban  communiBes  

Page 39: HEALTHSYSTEMTRANSFORMATION INMYANMAR RE THE … · 2016" !Expansion of payroll tax financed social health insurance for formal sector (private and civil servant)!" !Development of

Study  Design  Community-­‐based  cross-­‐secBonal  study  Part  I  :QuanBtaBve  methods    Part  II:  QualitaBve  methods  

Study  seing  All  resource-­‐limited  suburban  

communiBes  in  Mandalay  city  

Map of Mandalay city"

"  Formal  seZlements  "  Riverbank  seZlements  "  Polakee  seZlements  

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Data  collecHon  at  one  of  the  Polakee  CommuniHes  

Page 41: HEALTHSYSTEMTRANSFORMATION INMYANMAR RE THE … · 2016" !Expansion of payroll tax financed social health insurance for formal sector (private and civil servant)!" !Development of

I really want to go to school."

During  data  collecHon  at  one  of  the  Polakee  CommuniHes  

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•  Geographical  accessibility  (79%)    •  Financial  accessibility  (19%)    •  Overall,  only  34%  were  able  to  access  at  least  one  RH  service  centre  within  

30  minutes  walk  at  an  affordable  cost  and  were  aware  that  the  service  existed.    

Factor Adjusted OR (95% CI) P-value*

Youth's place of residence: ref.= Formal Settlements < 0.001

Polakee Settlements 0.36 (0.15-0.84)

Riverbank Settlements 0.29 (0.16-0.52)

LogisBc  regression  analysis  adjusBng  all  confounding  factors  OR:  Odds  RaBo;  CI:Confidence  Interval  

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44  

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●  Significant  increase  in  health  expenditures,  which  raise  the  share  of  GDP  allocated  to  health    ◦  From  2.4%  in  2012  to  3.14%  in  2013  and  3.82%  in  2015  ◦  Nine  fold  increase  from  2011  to  2015  ◦  Share  of  Public  Health  Expenditure  in  Total  Health  Expenditure  from  20%  to  34%  

●  Focus  on  medicines,  medical  equipment,  and  building  infrastructure  for  health  insurance  ●  Level  of  health  investment  is  sBll  low  compared  to  the  demand  for  health  care  ●  SBll  the  lowest  compared  to  other  countries  in  SEAR  

45  

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Department  of  Health’s  State  and  Region  Budget  AllocaHon  

0.  

7500.  

15000.  

22500.  

30000.  

Kachin  

Kayah  

Karen  

Chin  

Saga

ing    

Tanintha

ryi  

Bago

 

Mag

way  

Man

dalay  

Nay  Pyi  Taw

 

Mon

 

Rakhaing

 

Yang

on  

Shan

 (S)  

Shan

 (N)  

Shan

 (East)  

Ayeyarwad

dy  

2012-­‐13   2013-­‐14  

2014-­‐15  

Source:  Department  of  Health  Planning,  Ministry  of  Health,  Myanmar  

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47  

"    The  Social  Security  Law  (August  2012)  "    Full  medical  reimbursement  for  every  civil  

servant  (Civil  Servant  Medical  Benefit  Scheme)  in  2016  

"    Expansion of payroll tax financed social health insurance for formal sector (private and civil servant)  

"    Development of new social protection policy (2014) to provide health and social benefit for informal sectors  

"    Stakeholders’ meetings for development of feasible private health insurance for affordable population Department of Health Planning, MOH"

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Three  mechanism  to  cover  this  informal  sector:  ● Full  contribuBons  by  members  (the  Philippines)  ● ParBally  subsidized  by  the  Government  either      central  or  local  (Vietnam,  China)  ● Covered  by  tax  financed  scheme  (Thailand)  

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●  Human  Resources  for  Health  Master  Plan:  prepared  in  2012  for  the  next  20–30  years  ●  AppoinHng  new  health  care  workers:    

●  Many  professionals  graduated,  but  were  not  employed  by  the  government.    ●  Over  28  000  registered  medical  doctors:  about  12  000  were  employed  by  public  agencies  

●  Increased  salary:  Doctors  (from  150  US$  to  250  US$)  ●  Expansion  of  hospitals  and  beds  provision  ●  30  CT  scanners  by  the  end  of  2013:  available  in  the  general  hospitals  of  all  region  and  state  

Hospitals.  ●  Supplied  essenHal  drugs  to  the  hospitals  (Quick-­‐Win  approaches)  

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(MOH,  2013)  

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●  CollaboraBon  with  various  actors  in  Health  Sector  since  2011  ●  The  Three  Millennium  Development  Goals  (3MDG)  Fund  started  in  2013    ●  Many  other  internaBonal  nongovernmental  organizaBons    INGOs  (e.g.  PATH,  

MSI,  Save  the  Children,  World  Vision,  Oxfam,  Medecins  Sans  FronBeres,  AMDA,  ADRA,  CARE  InternaBonal,  Burnet  InsBtute,  Merlyn,  Malteser)    

●  Working  separately  to  finance  specific  health-­‐development  programmes  

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Source:  Stephan  Lock,  Global  PracBces,  2013  

"   Health-care systems are diverse in SEAR""   Range from dominant tax-based financing to

social insurance and high Out-of-pocket OOP payments"

"   Government spending is generally low in ASEAN, except Thailand and Brunei"

"   Singapore’s health system is the best based on international assessments"

"   Thailand’s Universal Health Coverage: the most successful story reaching the poor (98% coverage)"

"   Increased government health spending: the more significant gains"

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●  Myanmar  is  facing  a  very  important  transiHonal  period  ●  82%  of  total  health  spending  in  Myanmar  is  out-­‐of-­‐pocket,  the  highest  in  the  

world  ●  The  recent  increase  in  government  spending  for  health  is  encouraging;  however  

it  is  not  sufficient  ●  Social  ProtecHon  System  is  in  the  developmental  stage  ●  Financial-­‐risk  protecHon  for  the  majority  of  the  populaBon  who  are  poor  and  

from  informal  sectors  is  sBll  lacking  

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●  Human  resources  for  health  are  constrained  ●  Job  saHsfacHon  among  health  care  provider  is  unsaBsfactory  ●  InequiHes  in  distribuHon  of  the  health  workforce,  parBcularly  at  the  most  

peripheral  level  of  the  system  ●  Very  weak  health  informaHon  system  ●  A  large  influx  of  internaHonal  development  partners  and  donor  funding      

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1.   Equity  of  access  to  health  care:  of  vital  importance  2.   Government  commitment:  more  investment  in  health  3.   InternaHonal  aid:  adhere  to  the  Paris  DeclaraBon  on  Aid  EffecBveness  4.  The  country’s  future  healthcare  advancements  will  most  likely  stem  from  the  

private  sector:  appropriate  policies  should  be  considered  5.  No  major  evaluaHon  or  impact  study  has  been  carried  out  so  far  specifically  linked  

to  these  reforms  and  such  studies  are  strongly  suggested  

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1.  Asian  Development  Bank  (ADB)  (1996).  Country  synthesis  of  post  evaluaBon  finding  in  Myanmar.  Manila:  ADB  Post  EvaluaBon  Office.  

2.   Asian  Development  Bank  (ADB)  (2012).    Myanmar  in  transiBon:  opportuniBes  and  challenges.22  February  2013  3.  Central  StaBsBcal  OrganizaBon  (CSO)  (2009).  StaBsBcal  year  book  2008.  Nay  Pyi  Taw:  CSO,  Ministry  of  NaBonal  Planning  and  

Economic  Development.  4.  Central  StaBsBcal  OrganizaBon  (CSO)  (2012).  StaBsBcal  year  book  2011.  Nay  Pyi  Taw:  CSO,  Ministry  of  NaBonal  Planning  and  

Economic  Development.  5.  Department  of  Health  NaBonal  Tuberculosis  Programme  (DOH-­‐NTP)  (2011).  The  five-­‐year  NaBonal  Strategic  Plan  (NSP)  (2011–

2015).  Nay  Pyi  Taw:  DOH.  6.  Health  System  in  TransiBon,  The  Republic  of  Union  of  Myanmar,  Health  System  Review,  Asia  Health  Observatory  on  Health  

Systems  and  Policies  7.  World  Health  OrganizaBon  (WHO)  (2000).  The  world  health  report  2000.  Health  systems:  improving  performance.  Geneva:  WHO  

(hsp://  www.who.int/whr/2000/en/whr00_en.pdf,  accessed  26  November  2013].  8.  Handler  A,  Issel  M,  Turnock  B.  A  Conceptual  Framework  to  Measure  Performance  of  the  Public  Health  System.  American  Journal  

of  Public  Health.  2001;91(8):1235-­‐1239.  9.  Dhillon  PK,  Jeemon  P,  Arora  NK,  et  al.  Status  of  epidemiology  in  the  WHO  South-­‐East  Asia  region:  burden  of  disease,  

determinants  of  health  and  epidemiological  research,  workforce  and  training  capacity.  InternaNonal  Journal  of  Epidemiology.  2012;41(3):847-­‐860.  doi:10.1093/ije/dys046.  56  

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●  Prof.    Karen  Eggleston  and  all  the  members  of  APARC  ●  WHO-­‐HRP  for  the  financial  support  ●  DMR-­‐UM  and  Ministry  of  Health  (Myanmar)  ●  My  research  team  as  well  as  all  the  poor  and  marginalized  

groups  from  Myanmar  

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THANK  YOU!  

Welcome to Myanmar, the Golden Land!"